Skip to main content

Full text of "Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction"

See other formats


DEPENDENT PERSONALITY 
DISORDER AND OTHER 
PERSONALITY DISORDERS: A 
CRITICAL INTRODUCTION 

KEVIN BREWER 

ORSETT ACADEMIC MONOGRAPHS NO . 6 
ISBN: 978-1-904542-13-1 

PUBLISHED BY 

Orsett Psychological Services, 

PO Box 179, 

Grays, 

Essex 

RM16 3EW 

UK 

COPYRIGHT 

Kevin Brewer 2003 

COPYRIGHT NOTICE 

All rights reserved. Apart from any use for the 
purposes of research or private study, or criticism or 
review, this publication may not be reproduced, stored or 
transmitted in any form or by any means, without prior 
permission in writing of the publishers. In the case of 
reprographic reproduction only in accordance with the 
terms of the licences issued by the Copyright 
Licensing Agency in the UK, or in accordance with the 
terms of licences issued by the appropriate organization 
outside the UK. 



CONTENTS 



Page number 



INTRODUCTION 



HISTORY OF PERSONALITY DISORDERS 



DEPENDENT PERSONALITY DISORDER 8 

How many sufferers? 8 
Gender differences and Dependent 

Personality Disorder 10 

What is Dependent Personality Disorder? 12 

Overlaps in symptoms 17 



PROBLEMS WITH PERSONALITY DISORDERS 20 

1. Personality categories or dimensions 20 

2. Measurement of Personality Disorders 23 

3. The distinction between Personality 

Disorders and mental disorders 25 

4. Gender and Personality Disorders 29 

5. "Post-modern self" and Personality 

Disorders 30 



FOOTNOTES 33 



REFERENCES 37-42 



Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 
Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 



INTRODUCTION 

In the technical terms of psychiatry, mental illness 
covers mental disorders, personality disorders, and 
learning disabilities. The latter two are seen as 
distinct from the first. This monograph attempts to 
explore the many aspects of Personality Disorders (i) 
generally, and Dependent Personality Disorder 
specifically . 

Parker (1988) feels that Personality Disorders have 
a "lost planet status" in that researchers are unsure how 
to classify or measure them. Defining personality 
disorders generally has been difficult. 

Schneider (1923), for example, called them "abnormal 
personalities": "who suffer through their abnormalities 
and through whose abnormalities society suffers". Later 
Rado (1953) used: "Distress of psychodynamic integration 
that significantly affects the organism's adaptive life 
performance, and its attainment of utility and pleasure". 

More formally, ICD-9 (WHO 1978) expanded the 
definition to: 



Deeply ingrained maladaptive patterns of behaviour 
generally recognisable by the time of adolescence 
or earlier and continuing throughout most of adult 
life, although often becoming less obvious in middle 
and old age. The personality is abnormal either in 
the balance of its components, their quality and 
expression, or in its total aspect. 



And in DSM-IIIR (APA 1987) : "Behaviour or traits 
that are characteristic of the individual's recent (past 
year) and long-term functioning (generally since 
adolescence or early adulthood) . The constellation of 
types of behaviour or traits causes either significant 
impairment in social or occupational functioning, or 
subjective distress". 

Subsequent definitions in ICD and DSM have moved 
closer together. Personality Disorders are defined in 
DSM-IV and ICD-10 as "an enduring pattern of inner 
experience and behaviour that deviates markedly from the 
expectations of the individual's culture" (Farmer et al 
2002 pl53) . 

APA (2000) is more precise: "enduring patterns of 
perceiving, relating to, and thinking about the 
environment and oneself that are exhibited in a wide 
range of social and personal contexts" (p685) . 

The sufferer is seen as differing in terms of: 

Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 

Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 3 



a) Cognition - how they perceive and understand the 
world, events, and themselves; 

b) Affectivity - emotional responses: in terms of 
the range, intensity, and appropriateness; 

c) Interpersonal functioning - interactions with 
others; 

d) Impulse control. 

The individual will deviate from the norm in at 
least two of these areas, and that this behaviour is 
inflexible covering all situations of their lives over a 
long period with adolescent origins. The behaviour must 
also cause distress (APA 1994) . 



HISTORY OF PERSONALITY DISORDERS 

The idea of enduring characteristics has existed 
since early Greek writings, though terms other than 
personality have been used, like temperament, 
constitution, habit, or character (Berrios 1993) . 

In the 19th century, diagnostic categories were 
created which began the attempt to distinguish 
personality problems from other mental problems. For 
example, "mania without delusions" ("manie sans delire") 
by Pinel in France or "moral insanity" coined by Prichard 
in England (Berrios 1993) . But, in many cases, 
personality "disorder" at that time were seen as the 
result of failures in the "will" (Berrios 1993) . 

In terms of the current view on Personality 
Disorders, Kraeplin (1907) suggested that "personality 
disturbances" were a form of major psychoses, seeing them 
as a continuum. Whether Personality Disorders are 
different to mental disorders is still being debated 
today, and an alternative view comes from Jaspers 
(1927), who distinguished between personality 
developments and disease processes. 

While Schneider (1923) distinguished between 
"abnormal personality", which deviates from the average, 
and "disordered personality", an extreme version of the 
normal personality. A subgroup of "abnormal personality" 
was called "psychopathic personalities", and had ten 
variants. It is the term and concept of psychopathic that 
has dominated Personality Disorders. Even if the meaning 
has changed over the twentieth century. 

The forerunners of modern classification systems for 
mental disorders (eg: "Standard Classified Nomenclature 

Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 

Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 4 



of Disease" 1932) and the early versions of the current 
systems implicitly used personality disorder terminology 
and concepts . 

DSM-I (APA 1952) listed four categories of 
psychiatric disorder relating to personality: 
disturbances of pattern; disturbances of traits; 
disturbances of drive, control and relationships; and 
sociopathic disturbances. These forerunners of 
Personality Disorders were "used only when the patient 
did not fit comfortably in other categories" (Lenzenweger 
and Clarkin 1996) . However, explicit diagnostic criteria 
did not appear until DSM-III in 1980. 

It was also in DSM-III that Personality Disorders 
were first classified on a separate axis (Axis II) from 
other mental disorders (Axis I) . Subsequent developments 
and debates involved the refining of the criteria for 
diagnosis . 

For example, DSM-III used monothetic categories for 
diagnosis. These are set criteria that are necessary for 
diagnosis. Subsequent DSM systems have used polythetic 
categories where some of the criteria only are needed for 
diagnosis (eg: the presence of five from a list of seven 
to nine characteristics) . 

Currently ICD-10 (WHO 1992) and DSM-IV (APA 1994) 
are perceived as compatible, in the main, in their 
diagnostic criteria for Personality Disorders (table 1) 

(2) . 

DSM-IV divides the Personality Disorders into three 
common clusters (table 2) . 

The process of classification is never finished, and 
proposals for revisions are continually being discussed 
in committees preparing DSM-V for 2007. There is also 
ICD-11 due (Widiger 2001) . 

Livesley (2000) divides the history of Personality 
Disorders into three stages: pre-DSM-III; DSM-III phase; 
and post-DSM III era. 

Livesley (2001) sees a variety of concepts of 
Personality Disorders that underlie current definitions. 
Personality Disorders as: 

i) Extreme versions of mental disorders; 

ii) A failure to develop aspects of the normal 

personality (ie: deficit); 
iii) A particular type of personality structure; 
iv) Abnormal personality compared to the majority. 

The relationship between Personality Disorders and 
normal personality has focused on three key issues 
(Lenzenweger and Clarkin 1996) : 

Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 

Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 5 



ICD 10 



DSM IV 



Paranoid F60.0 
Schizoid F60 . 1 
Schizotypal* F21 
Dissocial F60.2 
Emotionally unstable, 

borderline type F60.31 
Emotionally unstable, 

impulsive type 
Histrionic F60.4 

Anxious F60 . 6 
Dependent F60.7 
Anankastic F60.5 



Paranoid 301.0 
Schizoid 301.20 
Schizotypal 301.22 
Antisocial 301.7 
Borderline 301.83 



Histrionic 301.50 
Narcissistic 301.81 
Avoidant 301.82 
Dependent 301.6 
Obsessive-compulsive 301.4 



Enduring personality 

change after catastrophic 

experience F07.0 
Enduring personality 

change after psychiatric 

illness 

Organic personality 
disorder* * 

Other specific personality 
disorders and mixed 
and other personality 
disorders F60.9 



Personality change due 

to general medical condition*** 
Personality disorder not 

otherwise specified 301.9 



Passive-aggressive 

(negativistic) **** 
Depressive**** 

* = included within section for schizophrenia, schizoptypal and delusional disorders. 

** = included within section for organic mental disorders. 

*** = included within section for mental disorders due to general medical condition 

not elsewhere classified. 

**** = included within appendix as proposed criteria. 

(After Widiger 2001) 

Table 1 - Comparison of the categories of Personality 
Disorders in ICD 10 and DSM IV. 



CLUSTER A 



CLUSTER B 



CLUSTER C 



DISORDERS OF ODD OR 
ECCENTRIC BEHAVIOUR 



DISORDERS OF 
DRAMATIC, 
EMOTIONAL OR 
ERRATIC BEHAVIOUR 



DISORDER INVOLVING 
ANXIOUS OR 
FEARFUL BEHAVIOUR 



Paranoid 
Schizoid 
Schizotypal 



Anti-Social 
Borderline 
Histrionic 
Narcissistic 



Avoidant 

Dependent 

Obsessive-Compulsive 



Table 2 
DSM-IV. 



The three clusters of Personality Disorders in 



Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 
Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 



i) Are Personality Disorders extreme versions of 
normal personality traits on a continuum or separate 
categories? 

ii) How to distinguish normal and abnormal 
personality traits, and the relationship between them? 

iii) The underlying structure of personality and 
Personality Disorders (ie: the theoretical basis to 
personality) . 



Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 
Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 



DEPENDENT PERSONALITY DISORDER 

Both ICD-10 and DSM-IV use the same term: Dependent 
Personality Disorder. It is placed in cluster C of the 
three clusters of Personality Disorders in DSM- IV. 



HOW MANY SUFFERERS? 

Establishing how many individuals suffer from a 
disorder is not easy, and often depends upon the method 
of study used. Table 4 summarises some of the main 
studies . 

The mean rate of Dependent Personality Disorder is 
2.2% (range 0-7.9) in non-clinical samples in studies 
between 1985-2003 (excluding Bornstein 1993) . The figures 
vary for specialist samples (eg: inpatients in 
psychiatric hospitals) (table 3), and Flynn, Matthews and 
Hollins (2002) found a diagnosis rate of 28% among 
thirty-six individuals with mild or moderate learning 
disabilities in specialist challenging behaviour in- 
patient services. 

In a sub-set of elderly patients with major 
depression, Abrams et al (1995 quoted in Clarkin and 
Abrams 1998) reported a 12% rate of Dependent Personality 
Disorder . 



NUMBER OF 
STUDIES 



TYPE OF SAMPLE 
(N) 



community (4150) 



RATE OF DEPENDENT RANGE 

PERSONALITY 

DISORDER (%) 

9 0-10 



outpatients in 
psychiatric hospitals 

inpatients at 
psychiatric hospitals 



21 



2-47 



4-51 



(DSM-III or DSM-IIIR used) 



Table 3 - Summary of studies on rate of Dependent 
Personality Disorder between 1983-91 reported in 
Bornstein (1993) . 



The accuracy of figures from the different types of 
samples depends on a number of factors: 

i) Accuracy of "community" samples depends upon the 
honesty of responses to questionnaires, or the accuracy 
of the measuring devices used; 



Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 
Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 



STUDY 



Baron et 
al (1985) 



Black et 
al (1993) 



PREVALENCE 
PERSONALITY 
DISORDERS (%) 
Dependent Any 







2.4 



/ 



33.1 



CRITERIA SAMPLE 



DSM-III 374 USA random of 

non-ill relatives of 
patients with 
schizophrenia 

DSM-III 127 USA family 

members of volunteers 
to advertisements 



Blanchard et 2.2 
al (1995) 



DSM-IIIR 93 USA from adverts, 
or friends of motor 
vehicle accident 
survivors with PTSD 



Bornstein 
(1993) 



5.0 



DSM-III/R 20 729 participants 
pooled data from 18 
studies (see table 3) 



Coid (2003) 



1.0-1.7 4.4-13.0 DSM-IV 



summary of 6 studies 
1995-2001; community 



Coryell & 
Zimmerman 
(1989) 



0.5 



14.6 DSM-III 185 USA first degree 

relatives of 
volunteers from 
advertisements 



Drake & 
Vaillant 
(1985) 



7.9 



23.0 DSM-III 369 USA males in 

longitudinal study of 
juvenile delinquents 
began in 1940s (not 
sufferers ) 



Maier et 
al (1995) 



Reich et 
al (1989) 



Samuels et 
al (2002) (3) 



1.6 



5.1 



0.1/0.1 



9.4 DSM-IIIR 320 Germany first 

degree relatives of 
109 community sample 

11.1 DSM-III 235 USA responses to 

random questionnaire 
to 401 residents in 
mid-western 
university town 

9.0/5.1 DSM-IV/ 742 34-94 yrs random 
ICD-10 community sample in 
Baltimore between 
1997-9 



(Data from Coid 2003; Mattia and Zimmerman 2001; Samuels 2002) 

Table 4 - Summary of main recent studies of the 
prevalence of Dependent Personality Disorder. 



ii) Individuals with Dependent Personality Disorder 
may not seek treatment, and thus figures for 
"outpatients" samples could be underestimates. 
Individuals diagnosed with other disorders in 



Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 
Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 



"outpatients" samples, and Dependent Personality Disorder 
symptoms missed. Thus underestimate. 

iii) High rates in the "inpatients" samples may be 
due to " inst itut ionalisat ion" which produces symptoms of 
dependency (Booth 1986) . Thus overestimate possible. 



GENDER DIFFERENCES AND DEPENDENT PERSONALITY DISORDER 

The studies in table 5 show significant gender 
differences in the rate of Dependent Personality 
Disorder. Bornstein (1993) reported a prevalence rate of 
11% for women and 8% for men. 



STUDY 



Alnaes & 

Torgerson 

(1988) 

Hayward & 
King (1990) 

Jackson et 
al (1991) 

Kass et 
al (1983) 



SAMPLE 

298 outpatients 

4 5 community 
112 inpatients 



2192 community 
531 outpatients 



Reich (1987) 170 outpatients 

Stangler & 500 outpatients 

Printz (1980) 

Zimmerman & 7 97 community 
Coryell (1989) 

TOTAL 



RATE OF DEPENDENT PERSONALITY 
DISORDER (%) 



FEMALE 
48 



25 



MALE 
46 



11 



OVERALL 

47 



17 



11 


5 


8 


9 


4 


7 


27 


16 


24 


4 


4 


4 



11' 



* X2 = 0.0005 

** Male total calculation includes two other studies which did not give female 
breakdown: Drake et al (1988) 396 community sample and 10% rate; Poldrugo & Forti 
(1988) 404 outpatients and 4% rate of Dependent Personality Disorder 

(DSM-III and DSM-IIIR used) 

Table 5 - Summary of studies showing gender differences 
in the rate of Dependent Personality Disorder 1983-91 
reported in Bornstein (1993) . 



Do the gender differences in the prevalence of 
Dependent Personality Disorder imply "something inherent 
about females, something about the way women are 
socialised in our society, and/or something about the 
biases that diagnosticians bring to this personality 



Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 
Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 



10 



disorder" (Peterson 1996 p399)? 

Pilgrim and Rogers (1993) offer three possible 
explanations for the differences in rates of mental 
illness between men and women: 

i) Society causes female mental illness through, for 
example, sex role expectations; 

ii) Methodological weaknesses in the collection of 
the data. This is discussed below in relation to 
Dependent Personality Disorder; 

iii) The labelling of traditional female behaviour 
as mental illness. This is explored later in the 
"Problems with Personality Disorders" section. 



Methodological Weaknesses 

a) Observer bias. 

Where gender differences are measured by 
questionnaires rather than diagnostic interviews or 
observer ratings, the size of the difference is reduced. 
This would suggest observer bias in the diagnostic 
interview or observer rating (Yeger and Miezitis 1985) . 



In other words, in the minds of clinicians and 
clinical researchers, femininity may be so strongly 
associated with dependency that when a person appears 
feminine, dependency is "automatically" (ie: 
unconsciously and reflexively) attributed to that 
individual (Bornstein 1993 pl31) . 



Widiger and Spitzer (1991) call this process 
"diagnostic sex bias". 



ii) The setting of the data collection. 

Widiger and Spitzer (1991) noted that the 
characteristics of the setting can influence the 
findings; eg: Veterans Administration (VA) hospital 
compared to State psychiatric hospital or private 
facility . 



iii) Gender bias in the diagnostic criteria. 

A "criterion sex bias" (Widiger and Spitzer 1991) . 
The concern that "some Axis II diagnoses reflect normal 

Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 

Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 11 



sex-role related behaviours that have been 

inappropriately labelled as pathological" (Bornstein 1993 
P 131) . 



WHAT IS DEPENDENT PERSONALITY DISORDER? 

Pre-DSM-III 

The concept of dependency as a problem has existed 
throughout the twentieth century, but it was not 
formalised until DSM-III (1980) . 

Fromm (1947) had pointed out that sufferers "feel 
lost when alone because they feel that they cannot do 
anything without help" (p62), and Millon (1981) noted 
that the dependent persons' "centres of gravity" lies in 
others : 



To protect themselves, dependents quickly submit 
and comply with what others wish, or make themselves 
so pleasing that no one could possibly want to 
abandon them (pl07) . 



Bornstein (1993) offers a "working definition" of 
the dependent personality type based on four components: 

i) Motivational - the need for guidance, support, 
and approval of others; 

ii) Cognitive - the perception of the self as 
powerless and others as powerful; 

iii) Affective - anxiety about being independent, or 
being evaluated; 

iv) Behavioural - seeking help and approval from 
others, and thus yielding to them to maintain it. 

In DSM-I (APA 1952), "dependent personality 
disorder" was included as a subtype of the "passive- 
aggressive personality", "passive-dependent type". This 
was characterised by "helplessness, indecisiveness, and a 
tendency to cling to others as a dependent child to a 
supporting parent" (p37). In DSM-II (APA 1968), it was 
included in "other personality disorders of specified 
types", but there was no description of the symptoms of 
"passive-dependent personality disorder" . 



Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 

Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 12 



DSM-III and After 

DSM-III (APA 1980) defined Dependent Personality 
Disorder based on three broad symptoms: (i) passivity in 
relationships, and an inability to function 
independently; (ii) the subordination of own needs to 
others; and (iii) a lack of self-confidence. 

Really it was not until DSM-IIIR (APA 1987) that 
clear symptoms of "a pervasive pattern of dependent and 
submissive behaviour, beginning in early adulthood and 
present in a variety of contexts" (p354) were described. 
Five or more of nine symptoms were required for 
diagnosis : 



Unable to make independent decisions 

Lets others make important decisions 

Excessive fear of rejection 

Difficulty in initiating events and activities 

Volunteers to perform unpleasant tasks in order 

to please others 
Feels helpless when alone 

Devastated when important relationships end 
Preoccupied with fears of abandonment 
Easily hurt by criticism or disapproval 



Symptoms 1, 2, 4 and 5 are behavioural, and the 
others are affective. Application 1 shows an example of 
the use of the diagnostic criteria. 



APPLICATION 1 
"CASE 1" (Benjamin 1996) : Married woman with child. 
Application of DSM-IIIR criteria in diagnosis: 

1 . Unable to make everyday decisions without help 
of mother, who lives nearby, and husband. 

2. Also for important decisions. 

3 . Agreed with others when thought wrong - 

eg: agreeing with mother to keep happy, or telling 

cousin's story of child sexual abuse when group 
therapist wanted more details. 

6. Upset when alone - eg: found sobbing by husband 
late at night: "I want my mommy". 

8 . Could not imagine surviving without mother or 
husband . 

9. Can't handle criticism - eg: upset when mother 
criticised her for always asking for help. 



Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 
Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 



13 



Bornstein (1993) noted a problem with the DSM-IIIR 
criteria, and it is also relevant to DSM-IV. The criteria 
are not completely independent. For example, symptoms 1 
and 2 are clearly related, and it is difficult to show 
one without the other, as are symptoms 7 and 8. 

DSM-IV removed symptom 3 from above, and defined 
Dependent Personality Disorder as: 



A pervasive and excessive need to be taken care of 
that leads to submissive and clinging behaviour and 
fears of separation, beginning in early adulthood 
and present in a variety of contexts.. 

(DSM-IV-TR APA 2000) . 



For diagnosis of Dependent Personality Disorder, 
DSM-IV requires the presence of at least five of the 
eight symptoms (applications 2,3 and 4) : 

1. Has difficulty making everyday decisions without 
an excessive amount of advice and reassurance from 
others . 

2. Needs others to assume responsibility for most 
major areas of life. 

3. Has difficulty expressing disagreement with 
others because of fear of loss of support or approval. 

4. Has difficulty initiating projects or doing 
things on own (because of lack of self-confidence than 
motivation or energy) . 

5. Goes to excessive lengths to gain nurturance and 
support from others, to point of volunteering to do 
things that are unpleasant. 

6. Feels uncomfortable or helpless when alone 
because of exaggerated fears of being unable to care for 
self. 

7. Urgently seeks another relationships as a source 
of care and support when a close relationship ends. 

8. Unrealistic preoccupation with fears of being 
left to take care of self (DSM-IV APA 1994 pp668-669) . 



Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 

Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 14 



APPLICATION 2 

"Matthew" (Spitzer et al 1994) 34-year-old single 
man living with mother. 

Application of DSM-IV criteria in diagnosis: 

3. Unhappy and angry with self because mother had 
told him not to marry girlfriend, and he had obeyed. 

5. Turned down promotion to remain near to two very 
close friends . 

6. Has lunch with two friends every workday and 
feels lost if friends miss day. 

7. Wants to find new girlfriend as soon as last 
relationship ended. 

8. Has not left mother's home except for one year 
at college, but returned because of homesickness; 
also separation anxiety as a child. 



APPLICATION 3 
"Mr.G" (Millon 1969) . 
Application of DSM-IV criteria in diagnosis: 

1. Worked in father's tailoring shop, but mother 
made sure he did no "hard or dirty work"; only son 
of six children, mother kept watch and limited his 
responsibilities as child; also 19-year-old son of 
first marriage guided his father's affairs. 

2. First marriage arranged by parents to "sturdy 
woman" . 

4. Lost job when factory closed, and then stayed at 
home waiting for something to happen. 

5. Teased at work, but willing to run errands and buy 
cigarettes for work-mates. 

7. Married second time to "motherly type". 



Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 

Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 15 







APPLICATION 4 








"Sarah D" (Carson 
two children. 


et al 1998) Married 


mother 


of 




App 


lication of DSM-IV criteria in dia 


gnosis : 






1/2 . Reported to 
abuse by husband 


"crisis centre" after physical 
needing to know what to do. 




3. 


Not critical o 


f husband's regular 


abuse . 






4. 
of 


Attempts to leave husband in past 
fear of "not being with M" . 


failed 


because 


5. 

whc 

hus 


Physical abuse 

then left . He 

band, and play 


by husband with add 
r main concern about 
ed down abuse . 


iction 
return 


probl 
of 


em, 


6. 

in 


Great concern 
well-paid job. 


about surviving on h 


er own, 


thou 


gh 


7. 


Similar relationships with first husband. 







Non-clinical definitions 

Gelder et al (1996), in their textbook of 
psychiatry, include two paragraphs about Dependent 
Personality Disorder. These are the main points they 
made : 

i) Weak-willed and "unduly compliant with wishes of 
others" ; 

ii) Lack vigour and "little capacity for enjoyment"; 

iii) Avoid responsibility and lack self-reliance; 

iv) Can achieve their aims by persuading others to 
help them while protesting their helplessness; 

v) If married, a "determined spouse" can make 
decisions etc; 



vi) "..left to themselves, some drift down the 
social scale and others are found among the long-term 
unemployed and the homeless" (pll7) . 

While Alloy et al (1993) emphasised the dependence 
on others, and the handing over of decisions to others. 
They see these symptoms as manifestations of the fear of 
abandonment, which can lead to mistreatment by those in 
control. The authors tend to see the sufferers as female. 

Brown (1992) would rather see the cause in society 
than in the individual. Ussher (2000) summarises the 
feminist critique of mental illness among women: 



Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 
Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 



16 



Within a heterosexual matrix, the traditional script 
of femininity tells us that women live their lives 
through men. To have a man, and keep him, is the goal 
of every girl's life.. The "good girl" is inevitably 
self-sacrificing, but she always gets her man., the 
sexual woman is always deemed to deserve all the 
condemnation she gets.. Women are taught to gain 
happiness through relationships, invariably with men. 
They are also taught that it is their fault if these 
fail (p220) . 



Sadock and Sadock (2003) note the characteristics of 
pessimism, self-doubt, passivity, and fears of expressing 
sexual and aggressive feelings: "An abusive, unfaithful, 
or alcoholic spouse may be tolerated for long periods to 
avoid disturbing the sense of attachment" (p814) . 

Comer's (2002) emphasis is upon the pattern of 
clinging, obedience, fear of separation, and the need to 
be taken care of. Overholser (1996) noted the dependency 
on a parent or spouse for where to live, what job to do, 
and which neighbours to like. Sufferers are sad, lonely, 
and dislike themselves. 

Recently, an internet-related version of Dependent 
Personality Disorder has been noted, characterised by 
"excessively depending on a cyber-being and on numerous 
fellow users, ever seeking their company, guidance, and 
reassurance, and fearing separation (Comer 2002 p433) . 
Such individuals can spend up to sixty hours per week in 
chat groups. However, this behaviour has also been linked 
to "substance-related disorder" or "impulse-control 
disorder" patterns by other researchers. 

There is also the situation of a shared psychotic 
disorder ("folie a deux") where the submissive member of 
the pair (with Dependent Personality Disorder) takes on 
the delusional system of the more assertive other (Sadock 
and Sadock 2003) . 



OVERLAPS IN SYMPTOMS 

Comer (2002) notes a number of prominent and central 
features of Dependent Personality Disorder which it has 
in common with other Personality Disorders, "leading to 
frequent misdiagnoses or to multiple diagnoses for a 
given client" (p409) (table 6) . 

The symptoms of Dependent Personality Disorder do 
overlap with other Personality Disorders and mental 
disorders, like all categories of mental illness. The key 
is to differentiate in diagnosis. 



Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 

Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 17 



PROMINENT FEATURES 
DEPENDENT PERSONALITY 
DISORDER 



NUMBER OF PERSONALITY DISORDERS 
WITH SAME FEATURE (out of 9) 



suspicious/distrust 
controlling/ 

manipulative 
sensitive 
depressed/helpless 



PERSONALITY DISORDERS WITH 4 PROMINENT FEATURES IN COMMON 
WITH DEPENDENT PERSONALITY DISORDER 
Borderline; Histrionic; Narcissistic 

PERSONALITY DISORDERS WITH 3 PROMINENT FEATURES IN COMMON 
WITH DEPENDENT PERSONALITY DISORDER 
Paranoid; Schizotypal 

PERSONALITY DISORDERS WITH 2 PROMINENT FEATURES IN COMMON 
WITH DEPENDENT PERSONALITY DISORDER 
Anti-Social; Avoidant; Obsessive-Compulsive 

PERSONALITY DISORDERS WITH PROMINENT FEATURES IN COMMON 

WITH DEPENDENT PERSONALITY DISORDER 

Schizoid 



CENTRAL FEATURES OF DEPENDENT PERSONALITY DISORDER 
relationship problems - feature in all other Personality 

Disorders 
self-critical - feature in 4 other Personality Disorders 
anxious/tense - feature in 6 other Personality Disorders 



WHERE DEPENDENT PERSONALITY DISORDER DISTINCT 
self-absorbed: Dependent Personality Disorder only one not 

having this feature 
aloof /isolated : one of 4 Personality Disorders not having 

this feature 
hostile: one of 4 Personality Disorders not having this 

feature 

(Data from Comer 2002) 

Table 6 - Comparison of prominent and central features 
between Dependent Personality Disorder and other 
Personality Disorders. 



Many individuals display dependent personality 
traits. Only when these traits are inflexible, 
maladapted, and persisting and cause significant 
functional impairment or subjective distress do 
they constitute dependent personality disorder 

(DSM-IV APA 1994 p668) . 



The characteristic of dependency can also be found 
in mood disorder, panic disorder and agoraphobia, or 
mental disorder caused by general medical condition, 
according to DSM-IV. But for Dependent Personality 



Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 
Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 



18 



Disorder, the dependency has an early onset, and is 
stable over time. Table 7 gives examples of overlapping 
symptoms among Dependent Personality Disorder and three 
other Personality Disorders. 



SYMPTOM 



fear of 
abandonment 

need for 
approval 



DEPENDENT PERSONALITY 
DISORDER 

respond with submissiveness 



leads to docile behaviour 



OTHER PERSONALITY 
DISORDERS 

Borderline - respond 
with emptiness/rage 

Histrionic - produces 
flamboyant active 
demands for attention 



hypersensitive maintain relationships 
to criticism 



Avoidant - leads 
to withdraw from 
relationships 



Table 7 - Comparison of overlapping symptoms between 
Dependent Personality Disorder and three other 
Personality Disorders. 



Comer (2002) notes similar symptoms of Dependent 
Personality Disorder with Separation Anxiety Disorder, 
and Dysthymic Disorder (table 8) . 



SEPARATION ANXIETY DISORDER DYSTHYMIC DISORDER 

1. Common features with Dependent Personality Disorder 



- "persistently and 
excessively fearful 

or reluctant to be alone 

or without major attachment 

figures at home or without 

significant adults in other 

settings" 

(DSM-IV APA 1994 pll3) 

- emphasis on separation fears 



low self-esteem 
feelings of hopelessness 
difficulty making decisions 



2. Differences to Dependent Personality Disorder 

- physical symptoms related - motivation of above due 
to separation in Separation to depression in Dysthymic 

Anxiety Disorder Disorder 

- Separation Anxiety - other depressive symptoms 
Disorder usually (eg: eating and sleeping 
associated with children problems) in Dysthymic Disorder 

Table 8 - Similarities and differences between Dependent 
Personality Disorder and Separation Anxiety Disorder and 
Dysthymic Disorder. 



Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 
Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 



19 



PROBLEMS WITH PERSONALITY DISORDERS 

Livesley (2001) admitted that a "consensus seems to 
be emerging among clinicians and researchers that there 
are fundamental problems with the DSM classification of 
personality disorders" (pl6) . 

Parker (1998) noted that: "The DSM three-cluster 
argot of 'eccentric', 'dramatic', and 'anxious and 
fearful' types has been widely accepted, despite the lack 
of empirical support . . " (pl25) . 

The problems with Personality Disorders can be 
explored through five areas . 



1 . Personality Categories or Dimensions 

DSM-IV sets out criteria for the diagnosis of each 
Personality Disorder. But each description is "an 
idealised typical case" which is not found in real life 
(Farmer et al 2002) . These are based on the idea of types 
or traits (4), which goes against the current view on 
measuring personality as dimensions (eg: Costa and McCrae 
1992; Five-Factor Model; FFM) (5). 

But the use of dimensions would assume that the 
characteristics are present in all individuals, but 
exaggerated in those with Personality Disorders (Marlowe 
1996) . 

The use of types or prototypes means that there has 
to be a cut-off point. Who decides the cut-off point for 
inclusion or exclusion within the category? Often a panel 
of experts (Widiger 1993) . 

If the cut-off point is the presence of five 
characteristics from a list, how to view the individual 
with four of those characteristics, and how do they 
compare to an individual with one (Widiger and Corbitt 
1994) ? 

The alternative approach would be to link 
Personality Disorders to the theories of personality 
dimensions. Trull (2000) sees the idea of "dimensional" 
models of personality and Personality Disorders covering 
a number of approaches: 

i) Quantify each symptom to show the degree of 
presence (eg: Widiger 1993); 

ii) Identify traits that underlie Personality 
Disorders. For example, factor analysis of the 
Personality Disorder criteria to reveal the dimensions 
underlying them (eg: Livesley and Jackson 1986; found 18 
trait dimensions); 



Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 

Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 20 



iii) The use of personality traits as the basis of 
Personality Disorders independent of the DSM-IV criteria. 

Cloninger et al (1993) suggest that Personality 
Disorders may be extremes of specific dimensions of 
personality rather than all dimensions. They divide 
personality traits into "temperament traits" (eg: 
novelty-seeking) and "character traits" (eg: co- 
operat iveness ) . It is the extreme version of the latter 
that would define Personality Disorders. 

Cloninger (2000) refined this idea to argue that 
Personality Disorders could be defined by two of the 
following four "character traits": low scores on self- 
direct iveness , co-operat iveness , affective stability, and 
self -transcendence. 

While a cluster C Personality Disorder would link to 
the FFM as high scores on Neuroticism, Agreeableness and 
Conscientiousness, and low scores on Extraversion and 
Openness (relationship unclear) (Farmer et al 2002) . 

Recent research has concentrated on the link between 
personality trait models and Personality Disorders, 
particularly the idea of a continuum between normality 
and abnormality on specific traits. 

Mulder and Joyce's (1997) factor analysis of the 
Personality Disorder symptoms of 148 patients produced a 
four factor model: "anti-social", "asocial", "asthenic", 
and "anankast ic" . This last factor was separately loaded 
by Obsessive-Compulsive Personality Disorder, and 
challenges the cluster C home for this disorder in 
DSM-IV (Parker 1998) . 

After the factor analysis, scores on the Structured 
Clinical Interview for DSM-III (SCID) (6) were correlated 
with "normal" personality questionnaires - Eysenck 
Personality Questionnaire (EPQ) (Eysenck and Eysenck 
1975) (7) and Tridimensional Personality Questionnaire 
(TPQ) (Cloninger et al 1991) (8) (table 9) . Parker (1998) 
feels that Personality Disorders are the "extremes of 
normally distributed human temperament measures". 



FACTOR MODEL EPQ TPQ 

anti-social psychoticism (P) novelty-seeking 

asocial psychoticism (P) reward dependence 

asthenic neuroticism (N) harm avoidance 

Table 9 - Correlations between personality factors and 
two personality questionnaires found by Mulder and Joyce 
(1997) . 



Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 

Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 21 



Blais (1997) looked at 100 patients with Personality 
Disorders and the FFM. The Personality Disorders linked 
best to the three dimensions of Neuroticism (N) , 
Extaversion (E), and Agreeableness (A) . 

Developing from this, Saulsman and Page (2003) note 
that the FFM reveals: 



the general personality traits underlying 
personality disorders, but (as) it does not account 
for all variance in personality disorders and 
appears to have difficulty differentiating specific 
personality disorders .. (p85 ) 



Common to all Personality Disorders, except 
Dependent Personality Disorder, with the FFM are high N 
(Neuroticism) and low A (Agreeableness) . Extraversion (E) 
and Conscientiousness (C) are linked to Personality 
Disorders but as associated variables, and Openness (0) 
has no association with any Personality Disorder. There 
are patterns for some specific Personality Disorders 
(table 10) . 



PERSONALITY DISORDER FFM DIMENSIONS 

Paranoid high N; low A 

Anti-Social low A; low C 

Avoidant high N; low E 

(After Saulsman and Page 2003) 

Table 10 - Examples of relationships between specific 
Personality Disorders and FFM dimensions. 



Duggan et al (2003), used for their study, 34 men 
with an offending history and a Personality Disorder in 
UK regional secure units. The researchers correlated the 
scores on the NEO-FFI (Neuroticism, Extraversion, 
Openness - Five Factor Inventory) (Costa and McCrae 1990) 
with the International Personality Disorder Examination 
(IPDE) (Loranger et al 1994) . Table 11 shows the 
significant correlations found. The sample used in this 
study was small and biased (ie: offenders) . 

In other words, it is possible to distinguish normal 
from disordered personality as deviation from the norm, 
extreme elevation, inflexibility, distress, and 
impairment in functioning (Saulsman and Page 2003) . 

But such an idea "seems to embrace an ideal concept 
of normality" which would blur the distinction between 



Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 

Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 22 



normality and clinically significant impairment even 
more, and "trivialising the disorder by creating a 
conception that would apply to a sizeable proportion of 
the population" (Liveley 2001 p25) . 



PERSONALITY N E A C 

DISORDER 
(No of sample) 

Paranoid (9)* (high) (low) (low) (low) low 

Schizoid (4) low 

Schizotypal (5) low 

Anti-Social (26) low 

Borderline (21) (high) low low 

Histrionic (6) low 

Narcissistic (3) 

Avoidant (11) low 

Dependent (4) high (low) 

Obsessive- 
Compulsive (3) low 

Passive- 
aggressive (15) high low 

Sadistic (7) (low) 

Self- 
defeating (3) (high) 

* = dual diagnosis means totals greater than 34; significance = 0.05 or (0.01) 
(After Duggan et al 2003) 

Table 11 - Summary of significant correlations between 
Personality Disorders and FFM found by Duggan et al 
(2003) . 

2 . Measurement of Personality Disorders 

Whether the questionnaire is self-reported (eg: 
Personality Assessment Inventory; PAI; Morey 1991) o> or 
part of a diagnostic interview (eg: Personality Disorder 
Interview; PDI-IV; Widiger et al 1995) (io>, the assumption 
is that personality types will show a pattern of 
responses to a series of choices. 

The scores will be compared to established norms. 
Well known general personality tests, like the Minnesota 
Multiphasic Personality Inventory (MMPI) (Hathaway and 
MacKinley 1967) are well researched, and have established 

Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 

Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 23 



validity and reliability scores (ii) . But, in practice, 
this focus on reliability, validity and norms has ignored 
the fact that the underlying assumptions for their design 
have problems . 



i) The assumption that personality is stable. 
Tickle et al (2001) admit that: 



Fluctuation in the expression of traits is expected: 
personality traits seem to be stable over time, but 
they do undergo slight state fluctuations in the 
short term. In other words, traits provide a basic 
personality framework which remains stable in the 
long term and allows patterns of responses to be 
established. There exists, however, a range of 
behaviours and other trait expressions that occur 
within this framework of stability (p246) . 



Wetherell and Maybin (1996), taking a social 
constructionist position, argue that the personality is 
the product of social situations. It is "the sum and 
swarm of participation in social life" (Bruner 1990), and 
thus tends to change based on the situation. 

The personality (or self, as preferred by social 
constructionists) is "always located in the situation in 
which the individual is existing. Identity is multi- 
faceted, but based on key relational settings" (Brewer 
2001a p33) . The concept of a stable personality is 
completely challenged, and so is the idea of a stable 
Personality Disorder. 

The method of assessing personality will also 
influence the findings of stability or not of the 
personality (Heatherton and Nichols 1994) . For example, 
self reporting scales of 1-5 tend to find stability 
because individuals who choose one extreme are unlikely 
to choose the other extreme next time. Maybe a change 
from 4 or 5 to 3. Or individuals may select the middle 
position each time. 



ii) The assumption that certain patterns of responses 
show certain personality types. 

It assumed that the views expressed are fixed 
attitudes which are linked to underlying personality 
traits. Billig (1991) challenges this idea: for him, 
attitudes are not "individual evaluative responses 
towards a given stimulus object. Instead, attitudes are 
stances taken in a matter of controversy: they are 
positions in arguments" (quoted in Potter 1996 ppl60- 

Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 

Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 24 



161) . 

The upshot is that individuals express different 
views depending on the situation, and what action it is 
the want to achieve with that attitude (Potter 1996) . 
Thus different responses will be given to personality 
questionnaires depending on the situation, who is 
administering the questionnaire and so forth. 



iii) Often the psychometric questionnaires are based upon 
the assumption of a normal distribution of answers. 



iv) These questionnaires are able to detect patterns of 
symptoms, but are these patterns really a Personality 
Disorder? 

The official answer is yes, because that Personality 
Disorder is shown by those symptoms. And so the argument 
goes round. 

Specifically, Bornstein (1993) admits that the 
internal validity of the Dependent Personality Disorder 
symptoms is "reasonably strong", but not the external 
validity. Internal validity relates to clusters of 
symptoms together as predicted by the classification 
system. While external validity is the relationship 
between Dependent Personality Disorders symptoms and 
specific independent behaviours. Bornstein (1993) is 
particularly concerned about symptom 4 in DSM-III: 
difficulty in initiating events or activities. 

Usually this situation can be resolved by 
establishing the validity of the criteria by correlation 
with expected independent behaviours. For example, a high 
score on an IQ test should positively correlate with 
intelligent behaviour in everyday life (eg: doing 
crosswords, answering quiz questions) . There are no 
clear independent behaviours for Personality Disorders - 
no "gold standard" (Lenzenweger and Clarkin 1996) . 

This is important to note because the reliability of 
measurement methods for Personality Disorders can and 
have been established. Reliability and validity are two 
different concepts, and gaining one does not 
automatically mean the other is achieved as well 
(Coolican 1990) <i2) . 



3. The distinction between Personality Disorders and 
mental disorders 

Foulds (1976) attempted to establish possible models 
for the relationship between Personality Disorders and 
mental disorders. Three of the models are important to 

Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 

Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 25 



mention here (figure 1) 



MODEL 1 SEPARATE CONDITIONS 

Mental Personality 

disorders disorders 





MODEL 2 



CONTINUUM 



Normality 



Personality 
disorders 



Mental 
disorders 



MODEL 3 



OVERLAPPING CONDITIONS 



Mental 
disorders 



Personality 
disorders 




(After Freeman 1993) 



Figure 1 - Three possible relationships between mental 
disorders and Personality Disorders. 



DSM-III was first to make the distinction between 
Axis-II (trait-related) problems of Personality Disorders 
and learning disabilities, and Axis-I (state-related) 
mental disorders. This would suggest model 1 in figure 1, 
or is it model 3? 

"Psychiatrists, and perhaps British psychiatrists 
more than most, are ambivalent about whether to regard 
personality disorders as mental illness" (Kendell 2002 
pllO) . Mental illness, or more specifically mental 
disorder, is not an exact term, in the sense of allowing 
it to be used as for deciding what is and is not a mental 



Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 
Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 



26 



disorder (Kendell 2002) . 

In fact, DSM-IV has a 146-word definition of mental 
disorder, which sets up the existence of a "clinically 
recognisable set of symptoms" (Kendell 2002) . But thus 
can be typical of psychology (and psychiatry) , it is 
easier to spot a behaviour than to define it. 

Kendell (2002) argues that the problem with 
establishing the relationship between Personality 
Disorders and mental disorders relates to the different 
concepts of "disorder" generally used in medicine and 
psychiatry. There are four main concepts: 

a) Socio-political - a disorder is a condition that 
is accepted as undesirable; 

b) Biomedical - an abnormal phenomena that places 
the species at a "biological disadvantage"; 

c) Biomedical and socio-political - a disorder is a 
biological dysfunction (ie: the failure to perform a 
natural function), and thus accepted as undesirable; 



d) Ostensive - disorder as a prototype category. 

It seems clear., that it impossible., to decide 
whether personality disorders are mental disorders 
or not, and that this will remain so until there 
is an agreed definition of mental disorder 
(Kendell 2002 pll3) . 



Gelder et al (1996) emphasised the role of unusual 
behaviour in making this "not always easy to make" 
distinction between Personality Disorders and mental 
disorders . 



If the personal has previously behaved normally 
and then begins to behave abnormally, he is said 
to have a mental disorder. If the person has 
always behaved abnormally, he is said to have 
a personality disorder (pl05) . 



Siever and Davis (1991) suggest that there is a 
continuum between Personality Disorders and mental 
disorders based on four behavioural processes: 
cognitive/perceptual; impulsivity/aggression; affective 
instability; and anxiety/inhibition. 

As to whether Personality Disorders and mental 
disorders are on a continuum or are distinctly different 
has always remained a question throughout the 
classification of mental illness. 

Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 

Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 27 



There are difficulties with Gelder et al ' s 
distinction : 

i) Problems of defining "normality". 

Brewer (2001b) noted the problems with establishing 
what is normal or abnormal using a continuum (figure 2) . 



NORMAL ABNORMAL 




B 




(After Brewer 2001b) 



Figure 2 - Normal-abnormal continuum. 



Some abnormalities are slight (area A in figure 2) 
and fall within the range of normal variation, while area 
D is clearly abnormal. The problem relates to points B 
and C, and which is normal or abnormal. This may vary 
depending on circumstances, culture, or the individual 
involved. In other words, the division between normal and 
abnormal is not fixed. 

Table 12 gives examples of these problems for 
Dependent Personality Disorder. 



POINT ON FIGURE 2 APPLICATION TO DEPENDENT PERSONALITY 

DISORDER 

A need advice from others before major 

career change (normal) 

B/C need help to decide which university to 

attend. Whether this is a problem depends 
on the individual being a teenager or 
middle aged, for example 

D cannot make ordinary decisions, like 

getting dressed without help of others 
on what to wear 

Table 12 - Dependent Personality Disorder and examples of 
positions on the continuum of normality and abnormality. 



ii) Unusual behaviour not spotted before. 



iii) How to assess if unusual behaviour is permanent or 
temporary? 

Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 

Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 28 



iv) Some behaviour changes are slow (eg: onset of some 
forms of schizophrenia) . 



v) Dependent Personality Disorder is sometimes classed as 
an "immature" Personality Disorder, which means that it 
improves over time (Tyrer et al 1993) . This challenges 
the idea of a stable and enduring pattern as distinct 
from mental disorders. 



4 . Gender and Personality Disorders 

There is concern that the diagnostic criteria for 
Personality Disorders are biased towards a particular 
gender. Frances et al (1995) argued that the inclusion of 
stereotypically feminine characteristics in the 
diagnostic criteria will lead to a bias towards the 
overdiagnosis of women. Dependent Personality Disorder is 
one such disorder. 

Kaplan (1983) argued that the DSM-III criteria for 
Dependent Personality Disorder are quite similar to the 
traditional female sex-role, and "singles out for 
scrutiny and therefore diagnosis the ways in which women 
express dependency but not the ways in which men express 
dependency" (p789) . 

For example, the financial dependence of the non- 
working wife on the working husband is symptomatic of 
Dependent Personality Disorder, but not the dependency of 
that husband on the wife to maintain the household and 
perform the child-rearing tasks (Bornstein 1993) . 

Studies with college students have found that the 
DSM-III and DSM-IIIR criteria of Dependent Personality 
Disorder are viewed as traditional feminine behaviour 
more often than traditional masculine behaviour (eg: 
Landrine 1989) . 

But in studies with psychiatrists and fictitious 
case histories, females were not more likely to be 
diagnosed with Dependent Personality Disorder than men 
(eg: Adler et al 1990) . 

On the other hand, Corbitt and Widiger (1995) argue 
that the differences in diagnosis rates of Personality 
Disorders may just be the gender differences in certain 
personality traits. Using the overdiagnosis of women with 
Histrionic Personality Disorder as an example, Widiger 
(2001) points out that the solution is not to make the 
criteria more masculine, but to increase the "behavioural 
specificity of the diagnostic criteria" (p76) . 

In other words, there is nothing intrinsically wrong 
with the Personality Disorder categories, it is just a 

Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 

Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 29 



question of tinkering with the diagnostic criteria. 

Throughout the history of DSM, there have been 
criticises about the gender bias of disorders. For 
example, Masochistic Personality Disorder in DSM III was 
changed to Self-Def eating Personality Disorder in DSM 
IIIR, and placed in the appendices. It was then removed 
from DSM IV because of pressure from feminist groups 
(Kirk and Kutchins 1992) . 

To counter the inherent gender bias towards greater 
female diagnosis, Caplan (1991) "invented" Delusional 
Dominating Personality Disorder (DDPD) , which was 
rejected by the APA DSM committee. 

There would be fourteen symptoms of this disorder, 
including "A tendency to feel inordinately threatened by 
women who fail to disguise their intelligence" or "a 
pathological need for flattery about one ' s sexual 
performance and/or the size of one's genitalia". To some 
degree, DDPD was a spoof, but there was a serious point 
about DSM and the pathology of women (Griffin 1997) . 



5. "Post-modern self" and Personality Disorders 

"Post-modern" is a commonly used term today, but it 
is an "amorphous thing": "The term itself hovers 
uncertainly in most current writings between - on the one 
hand - extremely complex and difficult philosophical 
senses, and - on the other - an extremely simplistic 
mediation as a nihilistic, cynical tendency in 
contemporary culture" (Docherty 1993 pi) . 

Polkinghorne (1992) lists the themes of "post-modern 
thought" as : 

i) Foundat ionlessness - there are no universals; "no 
sure epistemological foundation upon which knowledge can 
be built " . 

ii) Fragmentariness - reality is "a disunited, 
fragmented accumulation of disparate elements and events. 

iii) Constructivism - there is no world "out there" 
to discover, all knowledge is constructed; "human 
experience consists of meaningful interpretations of the 
real" . 

iv) Neopragmat ism - the criteria for understanding 
are not whether knowledge corresponds to reality, because 
this cannot be known in the "post-modern" world. Rather 
it is whether knowledge "functions successfully in 
guiding human action to fulfil intended purposes". 

Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 

Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 30 



From a social constructionist point of view, the 
self is a product of culture and society. Thus the type 
of society will influence (even determine) the self. 



As people live their lives they are continually 
making themselves as characters or personalities 
through the ways in which they reconcile and work 
with the raw materials of their social situation 

(Wetherell 1996 p305) 



Gergen (1991) sees the condition of "mult iphrenia" 
being at the heart of the "post-modern self" . This is a 
"new constellation of feelings and sensibilities, a new 
pattern of self-consciousness involving the splitting of 
the individual into a multiplicity of self-investments" 
(PP73-4). 

What happens in practice is that the self becomes 
"an open slate. . . on which persons may inscribe, erase, 
and rewrite their identities as the ever-shifting, ever- 
expanding, and incoherent networks of relationships 
invites or permits" (p228) . 

Gergen (2000) expands on this aspect of the "post- 
modern self". Individuals are "fractionated beings" 
because of: 

a) "Polyvocality" - "the plethora of conflicting 
information and opinion" . 

b) Plasticity - rapid change and throwaway 
relationships, which leave the inner life as a luxury. 

c) Repetition - individuals echo the media; eg: 
saying "I love you" to someone comes from romantic 
novels . 

d) Transcience - many and varied roles. 

The key notions, then, are uncertainty and change 
(Stevens and Wetherall 1996) . 

For some writers, this experience is negative or 
even pathological: today's self is "a mixture of 
disillusionment, boredom, confusion and celebration" 
(Thomas 1996) . Frosh (1991) sees "narcissistic 
personality disorders" as a direct result of "post-modern 
society" . These are a product of ego defence mechanisms 
that overevaluate a self that is threatened by the 
insecurity of the "post-modern" . 

Gottschalk (2000) takes the idea of the "post-modern 
self" being one of pathology further: 

Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 

Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 31 



post-modern selfhood proceeds across a landscape 
constantly radiating with 'low-level fear' and 
saturated by compelling media voices which 
obsessively recite stories of permanent catastrophe, 
random brutality, and constant dissatisfaction (p37) 



Thus "insanity" can be seen as a normal response to 
"post-modern society" . Gottschalk lists the 
characteristics of "post-modern society", along with 
"low-level fear", that "normalise, celebrate, and make 
acceptable psychosocial dispositions that... are 
fundamentally unhealthy" (p38) : 

a) "Telephrenic maps" - the intrusion of the media 
into the self, and the construction of reality through 
the camera. 

b) "Tense ambivalence" - for example, borderline 
dispositions, which "oscillate between complete 
indifference and passionate involvement" (pp28-9) . DSM-IV 
provides the label for such behaviour as "borderline 
personality disorder" . 



Borderline patients often struggle to maintain 
coherence in their selves against forces of 
excessive splitting of aspects of reality. It may 
be that their selves have already begun to 
collapse (Thomas 1996 p328) . 



c) "Reasonable suspicion" (or even paranoia in some 
cases) . 

d) "So fast so numb" - gratuitous images of death 
and dying. Writers have called this "necrophilic 
television" (Robbins 1994: "the catastrophic and the 
banal are rendered homogeneous and consumed with equal 
commitment") or the "pornography of dying" (Burgin 1990) 

e) "Sociopathic" characteristics including caring 
for the self only. 



Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 

Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 32 



FOOTNOTES 

1. Personality Disorder is written with capitals to refer 
to specific categories used by psychiatrists. When 
written in small letters, it refers to the concept of 
personality problems or disorders. 

2. The categories of Personality Disorders in ICD-10 and 
DSM-IV are developments from earlier categories in ICD-9 
and DSM-IIIR, for example (table 13) . 



ICD-9 DSM-IIIR 

Paranoid 
Affective 
Schizoid Schizoid 

Schizotypal 
Explosive 

Anankastic Obsessive-Compulsive 

Hysterical Histrionic 

Asthenic Dependent 

Personality disorder with Anti-social 

predominantly sociopathic 

or asocial manifestation 
Other personality disorder Narcissistic 

Avoidant 

Borderline 

Passive regressive 
Unspecified Personality disorder not 

otherwise specified 

Table 13 - A comparison of the categories of Personality 
Disorder in ICD-9 and DSM-IIIR. 



3. Samuels et al (2002) found cluster C Personality 
Disorders were greater in non-married individuals (6.6 
adjusted odds ratio) , and in those with high school 
education only (5.0 odds) . 

4. The trait and type theories of personality assume a 
hierarchical structure for personality based on levels of 
traits (eg: surface or higher order) (figure 3) (Thomas 
2002) . 

5. The Five-Factor Model (FFM) sees personality as based 
on the interaction of the positioning of the individual 
on five trait dimensions, Each one is subdivided into six 
facet traits (Livesley 2001) (table 14) . 



Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 

Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 33 



OVERALL PERSONALITY 



HIGHER 
ORDER 
TRAITS OR 
PERSONALITY 
DIMENSIONS 



D 



SURFACE 
TRAITS 



BEHAVIOURS 



Eg: extraversion 




Eg: friendly 



Talk to 
strangers 



Smile 
often 



Meet many 
people 



Figure 3 - Example of hierarchical structure of 
personality . 



Neuroticism - anxiety, hostility, depression, self- 
consciousness, impulsivity, vulnerability. 

Extraversion - warmth, gregariousness, assertiveness, 

activity, excitement seeking, positive emotions. 

Openness to experience - fantasy, aesthetics, feelings, 
actions, ideas, values. 

Agreeableness - trust, straightforwardness, altruism, 
compliance, modesty, tendermindedness . 

Conscientiousness - competence, order, dutifulness, 
achievement striving, self-discipline, 

deliberation . 

Table 14 - Facet traits of FFM. 



6. The latest version is Structured Clinical Interview 
for DSM-IV Axis-II Personality Disorders (SCID-II) (First 
et al 1997) . 

7. EPQ measures three dimensions of personality: 



Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 
Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 



34 



introvert-extravert (E) ; neurotic (or emotional) -stable 
(N) ; and psychoticism (P) . 

8. TPQ measures "temperment traits" of novelty-seeking 
(eg: "seeks thrilling adventure"; "spends on impulse"); 
reward dependence; and harm avoidance (fear) (Depue and 
Lenzenweger 2001) . 

9. Personality Assessment Inventory contains 344 items 
with a 4 point scale that takes 50 minutes to complete 

(Clark and Harrison 2001) . 

10. Personality Disorder Interview is based on 93 items 
scored by the interviewer as (absence), 1 ( "at-or-above 
threshold level of criteria"), or 2 (prominent 
characteristic) during a 90 minute interview (Clark and 
Harrison 2 001) . 

11. "Good" psychometric tests will have established 
reliability and validity 

Reliability - consistency of the test. 

i) Test-retest: consistency over time by correlating 
the score on the same test by the same individual at two 
points in time. 

ii) Parallel forms: correlation between two versions 
of the same test. 

iii) Internal: consistency of the test (eg: split- 
halves correlation of odd number and even number question 
scores) . 



Validity - degree to which the test measures what it 
claims to measure. 

i) Face/content: questions appear to measure what 
they claim to measure. 

ii) Construct: relationship between a theoretical 
construct and the test. 

iii) Convergent /concurrent : correlation between 
scores on two independent tests of the same construct. 

iv) Criterion: correlation between the scores on the 
test and a predicted independent behaviour. 

v) Discriminant: this aims to find correlations 
between different measures of the same behaviour (eg: 
test scores and observations of behaviour) . Sophisticated 

Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 

Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 35 



techniques like Multi-Trait Multi-Method (MTMM) (Campbell 
and Fiske 1959) also establish behaviours that should not 
go together. 

Table 15 shows the most important aspects of 
reliability and validity in the diagnosis of Dependent 
Personality Disorder. 



RELIABILITY 
test-retest 

VALIDITY 
face/content 

construct 

convergent 
criterion 

discriminant 

MTMM 



DEPENDENT PERSONALITY DISORDER 

same diagnosis or test score at two 
points in time 



dependent behaviour seems logical to 
expect from Dependent Personality 

Disorder 

dependency is a theoretical personality 
construct and will be made up of 
behaviours, like the need for others to 
help, and difficulty making own decisions 

two scores on different tests or two 
independent diagnoses 

predicted independent behaviour eg: 
indecisiveness unless others help make 

decisions 

measures of Dependent Personality 
Disorder from a test correlated with 
diagnosis by an observer or interview 

expected behaviour not expected 



- need others to 
make decisions 

- need others to 
care for them 

- afraid of being 

alone 



make own decisions 



care for self 



happy to be alone 



Table 15 - Reliability and validity and Dependent 
Personality Disorder. 

12. For example, Personality Psychopathy (PSY-5) 
(Harkness and McNulty 1994) has an average test-retest 
reliability in 0.70s, but the limited studies on 
convergent and discriminant validity "suggest that 
certain scales may tap somewhat different constructs" 
(Clark and Harrison 2001 p293) . Median test-retest 
reliability varies from 0.52 for Personality Diagnostic 
Questionnaire (PDQ-R) (Trull 1993) to 0.90 for Coolidge 
Axis II Inventory (CATI) (Coolidge and Merwin 1992) 
(Clark and Harrison 2001) . 



Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 
Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 



36 



REFERENCES 

Adler, D.A; Drake, R.E & Teague, G.B (1990) Clinicians' practices in 
personality assessment: does gender influence the use of DSM-III axis I? 
Comprehensive Psychiatry, 31, 125-133 

Alloy, L.B; Jacobson, N & Acocella, J (1993) Abnormal Psychology: 
Current Perspectives (8th ed) , Boston: McGraw-Hill 

Alnaes, R & Torgerson, S (1998) DSM-III symptom disorders (axis I) and 
personality disorders (axis II) in an outpatient population, Acta 
Psychiatrica Scandinavica, 78, 348-355 

American Psychiatric Association (1952) Diagnostic and Statistical 
Manual for Mental Disorders (1st ed) , Washington DC: American Psychiatric 
Association 

American Psychiatric Association (1968) Diagnostic and Statistical 
Manual for Mental Disorders (2rd ed) , Washington DC: American Psychiatric 
Association 

American Psychiatric Association (1980) Diagnostic and Statistical 
Manual for Mental Disorders (3rd ed) , Washington DC: American Psychiatric 
Association 

American Psychiatric Association (1987) Diagnostic and Statistical 
Manual for Mental Disorders (3rd ed revised), Washington DC: American 
Psychiatric Association 

American Psychiatric Association (1994) Diagnostic and Statistical 
Manual for Mental Disorders (4th ed) , Washington DC: American Psychiatric 
Association 

American Psychiatric Association (2000) Diagnostic and Statistical 
Manual for Mental Disorders (4th ed - text rev), Washington DC: American 
Psychiatric Association 

Baron, M; Gruen, R; Rainer, J.D; Kane, J; Asnis, L & Lord, S (1985) A 
family study of schizophrenic and normal control probands: implications for 
the spectrum concept of schizophrenia, American Journal of Psychiatry, 142, 
447-455 

Benjamin, L.S (1996) An interpersonal theory of personality disorders. 
In Clarkin & Lenzenweger op cit 

Berrios, G.E (1993) Personality disorders: a conceptual history. In 
Tyrer, P and Stein, G (eds) Personality Disorder Reviewed, London: Royal 
College of Psychiatrists 

Black, D.W; Noyes, R; Pfohl, B; Goldstein, R.B & Blum, N (1993) 
Personality disorders in obsessive-compulsive volunteers, well comparison 
subjects, and their first degree relatives, American Journal of Psychiatry, 
150, 1226-1232 

Blais, M.A (1997) Clinical ratings of the five factor model of 
personality and the DSM-IV personality disorders, Journal of Nervous Mental 
Disorders, 185, 388-393 

Blanchard, E.B; Hickling, E.J; Taylor, A.E & Loos, W (1995) Psychiatric 
morbidity associated with motor vehicle accidents, Journal of Nervous and 
Mental Disease, 183, 495-504 

Booth, T (1986) Institutional regimes and induced dependency in homes 
for the aged, The Gerontologist, 26, 418-423 

Bornstein, R.F (1993) The Dependent Personality, New York: Guilford 
Press 

Brewer, K (2001a) Social Constructionism - A New Force in Psychology? 
Orsett, Essex: Orsett Psychological Services 

Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 

Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 37 



Brewer, K (2001b) Clinical Psychology, Oxford: Heinemann 

Brown, L.S (1992) A feminist critique of the personality disorders. In 
Brown, L.S & Ballou, M (eds) Personality and Psychopathology : Feminist 
Reappraisals, New York: Guilford Press 

Bruner, J (1990) Acts of Meaning, Cmabridge, Ma: Harvard University 
Press 

Burgin, V (1990) Paranoiac space, New Formations, 12, 61-75 

Campbell, D.T & Fiske, D.W (1959) Convergent and discriminant 
validation by the MTMM matrix, Psychological Bulletin, 56, 81-105 

Caplan, P (1991) Delusional Dominating Personality Disorder (DDPD) , 
Feminism and Psychology, 1, 1, 171-172 

Carson, R.C; Butcher, J.N & Mineka, S (1998) Abnormal Psychology and 
Modern Life (1998 update), New York: Longman 

Clark, L.A & Harrison, J. A (2001) Assessment instruments. In op cit 
Livesley (ed) 

Clarkin, J.F & Lenzenweger, M.F (1996) (eds) Major Theories of 
Personality Disorder, New York: Guilford Press 

Clarkin, J.F & Abrams, R (1998) Personality disorders in the elderly, 
Current Opinions in Psychiatry, 11, 131-135 

Cloninger, C.R (1987) A systematic method for clinical description and 
classification of personality variants, Archives of General Psychiatry, 44, 
573-588 

Cloninger , C . R (2000) A practical way to diagnose personality disorder: 
a proposal, Journal of Personality Disorders, 14, 99-106 

Cloninger, C.R; Przybeck, T.R & Svrakic, D.M (1991) The Tridimensional 
Personality Questionnaire: US normative data, Psychological Reports, 69, 
1047-1051 

Cloninger, C.R; Svrakic, D.M & Przybeck, T.R (1993) A psychobiology 
model of temperament and character, Archives of General Psychiatry, 50, 975- 
990 

Coid, J (2003) Epidemiology, public health and the problem of 
personality disorder, British Journal of Psychiatry, 182, supp 44, s3-sl0 

Comer, R.J (2002) Fundamentals of Abnormal Psychology (3rd ed) , New 
York: Worth 

Coolican, H (1990) Research Methods and Statistics in Psychology, 
London: Hodder & Stoughton 

Coolidge, F.L & Merwin, M.M (1992) Reliability and validity of the 
Coolidge Axis II Inventory: a new inventory for the assessment of 
personality disorders, Journal of Personality Assessment, 59, 223-238 

Corbitt, E.M & Widiger, T.A (1995) Sex differences among the 
personality disorders: an exploration of the data, Clinical Psychology: 
Science and Practice, 2, 225-238 

Coryell, W.H & Zimmerman, M (1989) Personality disorders in the 
families of depressed, schizophrenic, and never-ill probands, American 
Journal of Psychiatry, 146, 496-502 

Costa, P.T & McCrae, R (1990) Personality disorders and the five factor 
model of personality, Journal of Personality Disorders, 4, 362-371 

Costa, P.T & McCrae, R.R (1992) Revised NEO Personality Inventory (NEO- 
PI-R) and NEO Five-Factor Inventory (NEO-FFI) : Professional Manual, Odessa, 
FL: Psychological Assessment Resources 

Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 

Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 38 



Depue, R.A & Lenzenweger, M.F (2001) A neurobehavioural dimensional 
model . In op cit Livesley (ed) 

Docherty, T (1993) Postmodernism: an introduction. In Docherty, T (ed) 
Postmodernism: A Reader, New York: Harvester Wheatsheaf 

Drake, R.E & Vaillant, G.E (1985) A validity study of Axis II of DSM 
III, American Journal of Psychiatry, 142, 553-558 

Drake, R.E; Adler, D.A & Vaillant, G.E (1988) Antecedents of 
personality disorders in a community sample of men, Journal of Personality 
Disorders, 2, 60-68 

Duggan, C; Milton, J; Egan, V; McCarthy, L; Palmer, B & Lee, A (2003) 
Theories of general personality and mental disorder, British Journal of 
Psychiatry, 182, supp 44, sl9-s23 

Eysenck, H & Eysenck, S.B.G (1975) Manual of the Eysenck Personality 
Questionnaire, London: Hodder & Stoughton 

Farmer, A; McGuffin, P & Williams, J (2002) Measuring Psychopathology, 
Oxford: Oxford University Press 

First, M; Gibbon, M; Spitzer, R.L; Williams, J.B.W & 
Benjamin, L.S (1997) User's Guide for the Structured Clinical Interview for 
DSM-IV Axis II Personality Disorders, Washington DC: American Psychiatric 
Association 

Flynn, A; Matthews, H & Hollins, S (2002) Validity of diagnosis of 
personality disorders in adults with learning disabilities and severe 
behaviour problems, British Journal of Psychiatry, 180, 543-546 

Foulds, G.A (1976) The Hierarchical Nature of Personal Illness, London: 
Academic Press 

Frances, A.J; First, M.B & Pincus, H.A (1995) DSM IV Guidebook, 
Washington DC: American Psychiatric Association 

Freeman, C.P.L (1993) Personality disorders. In Kendell, R.E & Zealley, 
A.K (eds) Companion to Psychiatric Studies (5th ed) , Edinburgh: Churchill 
Livingstone 

Fromm, E (1947) Man For Himself, New York: Rinehart 

Frosh, S (1991) Identity Crisis: Modernity, Psychoanalysis and the 
Self, London: Macmillan 

Gelder, M; Gath, D; Mayou, R & Cowen, P (1996) Oxford Textbook of 
Psychiatry (3rd ed) , Oxford: Oxford University Press 

Gergen, K (1991) The Saturated Self: Dilemmas of Identity in 
Contemporary Life, New York: Basic Books 

Gergen, K (2000) The self: transfiguration by technology. In Fee, D 
(ed) Pathology and the Postmodern, London: Sage 

Gottschalk, S (2000) Escape from insanity: "mental disorder" in the 
post-modern moment. In Fee, D (ed) Pathology and the Postmodern, London: 
Sage 

Griffin, C (1997) A feminist perspective on psychology, Psychology 
Teaching, October, 4-12 

Harkness, A.R & McNulty, J.L (1994) The Personality 
Psychopathology Five (PSY-5) : issues from the pages of a 

diagnostic manual instead of a dictionary. In Strack, S & Lorr, M (eds) 
Differentiating Normal and Abnormal Personality, New York: Springer 

Hathaway, S.R & McKinley, J.C (1967) The MMPI Manual (rev ed) , New 
York: Psychological Corp 



Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 

Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 39 



Hayward, C & King, R (1990) Somatisation and personality disorder 
traits in non-clinical volunteers, Journal of Personality Disorders, 4, 402- 
406 

Heatherton, T.F & Nichols, P. A (1994) Conceptual issues in assessing 
whether personality can change. In Heatherton, T.F & Weinberger, J.L (eds) 
Can Personality Change? Washington DC: American Psychological Association 

Jackson, H.J; Whiteside, H.L; Bates, G.W; Bell, R; Rudd, R.P & Edwards, 
J (1991) Diagnosing personality disorders in psychiatric inpatients Acta 
Psychiatrica Scandinavica, 83, 206-213 

Jaspers, K (1923) General Psychopathology (translation), Chicago: 
University of Chicago Press 

Kaplan, M (1983) A woman's view of DSM-III, American 
Psychologist, 38, 786-792 

Kass, F; Spitzer, R.L & Williams, J.B.W (1983) An empirical study of 
the issue of sex bias in the diagnostic criteria of DSM-III Axis II 
personality disorders, American Psychologist, 38, 799-801 

Kendell, R.E (2002) The distinction between personality disorder and 
mental illness, British Journal of Psychiatry, 180, 110-115 

Kirk, S.A & Kutchins, H (1992) The Selling of DSM: The Rhetoric of 
Science in Psychiatry, New York: Aldine de Gruyter 

Kraeplin, E (1907) Clinical Psychiatry (translation), New York: 
Macmillan 

Landrine, H (1989) The politics of personality disorder, Psychology of 
Women Quarterly, 13, 325-339 

Lenzenweger, M.F & Clarkin, J.F (1996) The personality disorders: 
history, classification and research issues. In op cit Clarkin & Lenzenweger 

Livesley, W.J (2000) Introduction to special feature: critical issues 
in classification of personality disorders, Part I, Journal of Personality 
Disorders, 14, 1-2 

Livesley, W.J (2001) Conceptual and taxonomic issues. In op cit 
Livesley (ed) 

Livesley, W.J (2001) (ed) Handbook of Personality Disorders, New York: 
Guilford Press 

Livesley, W.J & Jackson, D.N (1986) The internal consistency and 
factorial structure of behaviours judged to be associated with DSM-III 
personality disorders, American Journal of Psychiatry, 143, 1473-1474 

Loranger, A.W; Sartorius, N; Andreoli, A et al (1994) The International 
Personality Disorder Examination: the WHO/ADAMHA international pilot study 
of personality disorders, Archives of General Psychiatry, 51, 215-224 

Maier, W; Minges, J; Lichtermann, D & Haun, R (1995) Personality 
disorders and personality variations in relatives of patients with bipolar 
affective disorder, Journal of Affective Disorder, 53, 173-181 

Marlowe, M.J (1996) "Biological aspects of personality disorders. In 
Katz, D (ed) Developments in Psychiatry, Salisbury: Quay Books 

Mattia, J.I & Zimmerman, M (2001) Epidemiology. In op cit Livesley (ed) 

Millon, T (1969) Modern Psychopath: A Biosocial Approach to Maladaptive 
Learning and Functioning, Philadelphia: Saunders 

Millon, T (1981) Disorders of Personality: DSM-III Axis 2, New York: 
Wiley 

Morey, L.C (1991) Personality Assessment Inventory, 

Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 

Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 40 



Odessa, FL: Psychological Assessment Resources 

Mulder, R.T & Joyce, P.R (1997) Temperament and the structure of 
personality disorder symptoms, Psychological Medicine, 27, 99-106 

Overholser, J.C (1996) The dependent personality and 
interpersonal problems, Journal of Nervous Mental Disorders, 184, 1, 8-16 

Parker, G (1998) Personality disorders as alien territory: 
classification, measurement and border issues, Current Opinion in 
Psychiatry, 11, 125-129 

Peterson, C (1996) Psychology of Abnormality, Fort Worth: Harcourt- 
Brace 

Pilgrim, D & Rogers, A (1993) A Sociology of Mental Health and Illness, 
London: Routledge 

Poldrugo, F & Forti, B (1988) Personality disorders and alcoholism 
treatment outcome, Drug and Alcohol Dependence, 21, 171-176 

Polkinghorne, D.E (1992) Postmodern epistemology of practice. In Kvale, 
S (ed) Psychology and Postmodernism, London: Sage 

Potter, J (1996) Attitudes, social representations and discursive 
psychology. In Wetherell, M (ed) Identities, Groups and Social Issues, 
London: Sage 

Rado, S (1953) Dynamics and classification of disordered behaviour, 
American Journal of Psychiatry, 110, 406-416 

Reich, J (1987) Sex distribution of DSM-III personality disorders in 
psychiatric outpatients, American Journal of Psychiatry, 144, 485-488 

Reich, J (1990) Comparisons of males and females with DSM-III dependent 
personality disorder, Psychiatric Research, 32, 2, 207-214 

Reich, J; Yates, W & Nduaguba, M (1989) Prevalence of DSM III 
personality disorders in the community, Social Psychiatry and Psychiatric 
Epidemiology, 24, 12-16 

Robbins, K (1994) Forces of consumption: from the symbolic to the 
psychotic, Media, Culture and Society, 16, 449-468 

Sadock, B.J & Sadock, V.A (2003) Kaplan and Sadock's Synopsis of 
Psychiatry (9th ed) , Philadelphia: Lippincott Williams & Wilkins 

Samuels, J et al (2002) Prevalence and correlates of 
personality disorders in a community sample, British Journal of Psychiatry, 
180, 536-542 

Saulsman, L.M & Page, A.C (2003) Can trait measures diagnose 
personality disorders? Current Opinion in Psychiatry, 16, 83-88 

Schneider, K (1950) Psychopathic personalities (9th ed) (translation), 
London: Cassell 

Siever, L & Davis, K (1991) A psychobiology perspective on personality 
disorders, American Journal of Psychiatry, 148, 1647-1658 

Spitzer, R.L; Gibbon, M; Skodol, A.E; Williams, J.B.W & First, M.B 
(1994) (eds) DSM-IV Casebook: A Learning Companion to the Diagnostic and 
Statistical Manual of Mental Disorders, 4th ed, Washington DC: American 
Psychiatric Association 

Stangler, R.S & Printz, A.M (1980) DSM-III: psychiatric diagnosis in a 
university population, American Journal of Psychiatry, 137, 937-940 

Stevens, R & Wetherell, M (1996) The self in the modern world: drawing 
together the threads. In Stevens, R (ed) Understanding the Self, London: 
Sage 

Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 

Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 41 



Thomas, K (1996) The defensive self: a psychodynamic 
perspective. In Stevens, R (ed) Understanding the Self, London: Sage 

Thomas, K (2002) The individual differences approach to personality. In 
Miell, D; Phoenix, A & Thomas, K (eds) Mapping Psychology 1, Milton Keynes: 
Open University 

Tickle, J.J; Heatherton, T.F & Wittenberg, L.G (2001) Can personality 
change? In op cit Livesley (ed) 

Trull, T.J (1993) Temporal stability and validity of two personality 
disorder inventories, Psychological Assessment, 5, 11-18 

Trull, T.J (2000) Dimensional models of personality disorder, Current 
Opinion in Psychiatry, 13, 179-184 

Tyrer, P; Casey, P & Ferguson, B (1993) Personality disorders in 
perspective. In Tyrer, P and Stein, G (eds) Personality Disorder Reviewed, 
London: Royal College of Psychiatrists 

Ussher, J (2000) Women's madness: a material-discursive-intrapsychic 
approach. In Fee, D (ed) Pathology and the Postmodern, London: Sage 

Wetherell, M (1996) Life histories/social histories. In Wetherell, M 
(ed) Identities, Groups and Social Issues, London: Sage 

Wetherell, M & Maybin, J (1996) The distributed self: a social 
constructionist perspective. In Stevens, R (ed) Understanding the Self, 
London: Sage 

Widiger, T.A (1993) The DSM IIIR categorical personality disorders: a 
critique and an alternative, Psychological Inquiry, 4, 75-90 

Widiger, T.A (2001) Official classification systems. In op cit Livesley 
(ed) 

Widiger, T.A & Corbitt, E (1994) Normal versus abnormal personality 
from the perspective of the DSM. In Strack, S.B & Lorr, M (eds), New York: 
Springer 

Widiger, T.A & Spitzer, R.L (1991) Sex bias in the diagnosis of 
personality disorders: conceptual and methodological issues, Clinical 
Psychology Review, 11, 1-22 

Widiger, T.A; Mangine, S; Corbitt, E.M; Ellis, C.G & Thomas, G.V (1995) 
Personality Disorder Interview - IV: A Semi-Structured Interview for 
Assessment of Personality Disorders, Odessa, FL: Psychological Assessment 
Resources 

World Health Organisation (1978) ICD-9: Mental Disorders: Glossary and 
Guide to their Classification in accordance with the 9th Revision of the 
International Classification of Diseases, Geneva: WHO 

World Health Organisation (1992) The ICD-10 Classification of Mental 
and Behavioural Disorders, Geneva: WHO 

Yeger, T & Miezitis, S (1985) Pupil sex as it relates to the pupil- 
teacher dependency relationship, International Journal of Women's Studies, 
8, 457-464 

Zimmerman, M & Coryell, W (1989) DSM-III personality disorder diagnoses 
in a non-patient sample, Archives of General Psychiatry, 46, 682-689 



Dependent Personality Disorder and Other Personality Disorders: A Critical Introduction 

Kevin Brewer; 2003; ISBN: 978-1-904542-13-1 42